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12054366 Published by J. J. KELLER 8 ASSOCIATES, INC Q, Neenah, WI • USA • (600) 327-6868 a www.hkeller.com • Printed in the United Slates 1617-13LS•C 6 10495
<br /> Please print or typo. (Form designed for use on elite (12-pitch) lypemi(er.) Form Approved. OMB No. 205"039
<br /> UNIFORM HAZARDOUS 1 .-Generator ID Number 2: Pagel of 3. Emorgency Response Phone 4, Manifest Trackln NuI III
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<br /> WASTE MANIFEST �.,� r a p �, 10119 0775
<br /> S. GenomloesName and > JJ
<br /> MalingAt(dress
<br /> .` t N✓r�: oN i 9r i ! �A� f �� < Ami frx's Silo Address (f different than making addross)
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<br /> Jrvck ,-oil C'_A 45�v� o6 S acr� i'on/ : 614 t750 oZ
<br /> Gonefalor'sPtwne: „14 ;` - q(& 0 / J o) O j Alec- i o .1 }!
<br /> 6. Tran"ier t Company Nano U.S. EPA ID Number
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<br /> 7,
<br /> 7, Transporter 2 Company Name
<br /> U.S. EPA ID Number
<br /> 8 Designated racUify Name and SiloAddtess U,S, EPA ID Number
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<br /> Fao'U 4Phone: Sl� .r - Vj.� CAE) r'Jot �$ r r3 9 0 47
<br /> ga, gb, U.S. DOT Descriplion (indudfng Proper Shipping Name, Hazard Class, ID Number, 10. Contalners 11- Talal 12, Unit
<br /> HM and Paining Group Of ary)) 13. Waste Codes
<br /> No. Typo Quantity WLNoI,
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<br /> 4. IP 11
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<br /> 14, Spodal NandAg Irnlruc6ans and Afld l en81 fnforrr 533
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<br /> !✓ E,4A 4PF'irao ria rAw, /"PE. r:t-'rif , flAeoq,VLIG, nl te, /40, 451 lf : r O C r�ru •.+ •`- eL 5r r44e *4 AA C>1 r orsfJq
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<br /> 15, GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fullyand accurately described above by the proper shipping name, and are dassirted, packaged,
<br /> marked and labeled/placarded, and aro In all respects in proper condition for transport according to applicable international and national gtrremmenlal regulations. If export shipment and I am the Primary
<br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consem, —
<br /> I carli(y that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quanlity generator) or (b) (if li ?na 5m? Uaniily generator) is Uue,
<br /> Gnrinlalofsr0lf cols Prin ypad N�rno Slpnaturo
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<br /> ❑ Import to U.S, Lf Export from U,S. Port of 0nbylexil:
<br /> Transporter signature. (for exports only): Date leaving U,S.:
<br /> W 17. Transporter AdmowledgrnentofReceipt ofMaterials
<br /> Tmnsponat 1 Pdnledffyped Name S analu Maoth Day Year
<br /> ZZTrarlWnP2PrfrliMlypcdName Sijjrf urn r' Monet Day Year
<br /> 18. Discrepancy
<br /> 180. Discrepancy Indication Space Quantity ❑ Type
<br /> ❑ Residue ❑ Partial Rejection ❑ Full Rejection
<br /> Manifest Reference NumLer.
<br /> 18b. fJlenhate FarJty (or Generator) US. EPA ID Number
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<br /> Ll Fau7ly'sPhone:
<br /> H180 SignaltHe of Allem-810 Facility (or Ganeralar) Month Day Year
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<br /> w19. Hazardous Waste Report Management Method Codes (i,e„ codes for hazardous waste treatment, disposal, and mdyiJing systems)
<br /> a 1 2. 3.
<br /> 4,
<br /> 20. Designated Fadlfty Omer or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Prmled/tgpedNama „igonlure htordh Day Year
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